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Devoted CHOICE GIVEBACK Hawaii (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted CHOICE GIVEBACK Hawaii (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted CHOICE GIVEBACK Hawaii (PPO) in 2025, please refer to our full plan details page.
Devoted CHOICE GIVEBACK Hawaii (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Honolulu, Kauai Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Devoted CHOICE GIVEBACK Hawaii (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted CHOICE GIVEBACK Hawaii (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Devoted CHOICE GIVEBACK Hawaii (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $117.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $450.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan has a $450 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, for a standard pharmacy, you will pay a $1 copay for preferred generic drugs, 21% coinsurance for standard generic drugs, and 25% coinsurance for preferred brand drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan offers a range of benefits including inpatient hospital stays, outpatient services, and emergency care with varying copays. This plan also covers primary care, preventive services, hearing, vision, and dental services, with specific copays and coverage limits. Additional benefits include home health services, skilled nursing facility stays, and medical equipment, with services like acupuncture also covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered with prior authorization. For inpatient hospital-acute, you will pay a $375 copay for days 1-4, and no copay for days 5-90; for inpatient hospital psychiatric care, you will also pay a $375 copay for days 1-4, and no copay for days 5-90. Additional days for inpatient hospital-acute are covered, while non-Medicare-covered stays and upgrades for inpatient hospital-acute, and additional days and non-Medicare-covered stays for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $475, and observation services have a $375 copay. Ambulatory surgical center services have no copay, and outpatient substance abuse individual and group sessions have a copay of $45.00.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan, and requires prior authorization. You will pay a $70 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay between $0 and $350, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $110 copay, and a $110 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, while Worldwide Emergency Transportation has a 20% coinsurance and a $350 copay.
Primary Care See details
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers Primary Care Physician Services, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $35 copay, Physician Specialist Services with a $55 copay, Mental Health Specialty Services with a $45 copay for both individual and group sessions, Other Health Care Professional services with a copay between $0 and $55, Psychiatric Services with a $45 copay for both individual and group sessions, Physical Therapy and Speech-Language Pathology Services with a $50 copay, and Opioid Treatment Program Services with a $45 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers preventive services, including annual physical exams, health education, weight management programs, alternative therapies, therapeutic massage, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, adult day health services, home-based palliative care, in-home support services, support for caregivers, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams, with a $50 copay, and prescription hearing aids. Routine hearing exams are covered for 1 visit per year with a $50 copay, and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids (all types) are covered for 2 visits per year with a copay between $599 and $899, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $15 copay, and for eyewear with a combined maximum benefit of $250 every year for both in-network and out-of-network services. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. This plan offers a maximum benefit of $250 per year for other dental services, and a $55 copay for Medicare dental services. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 15% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with a 20% coinsurance and no copay; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers Diagnostic and Radiological Services, including Diagnostic Procedures/Tests with a copay between $0 and $95, Lab Services with no copay, and Outpatient X-Ray Services with no copay. Diagnostic Radiological Services have a copay up to $300, and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted CHOICE GIVEBACK Hawaii (PPO) plan. For days 1-20 and 61-100, there is no copay, and for days 21-60, the copay is $140. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Devoted CHOICE GIVEBACK Hawaii (PPO) plan covers acupuncture with no copay, but does not cover over-the-counter items, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services. The plan also covers Other 2 services, which includes $0 preventive services.
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